Case report The prognostic factors of HIV-negative adult cryptococcal meningitis with a focus on cranial MRI-based neuroimaging findings Wan-Chen Tsai a,1 , Chia-Yi Lien a,1 , Jun-Jun Lee a , Wei-Che Lin b , Che-Wei Hsu a , Chi-Ren Huang a , Nai-Wen Tsai a , Chiung-Chih Chang a , Cheng-Hsien Lu a , Wen-Neng Chang a,⇑ a Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan b Department of Radiology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan article info Article history: Received 1 April 2018 Accepted 25 June 2018 Available online xxxx Keywords: Acute/subacute cerebral infarct Basal meningeal enhancement Cryptococcal meningitis HIV-negative MRI Prognostic factor Seizure abstract The prognostic significance of clinical characteristics and neuroimaging features, especially cranial mag- netic resonance imaging (MRI)-based neuroimaging features, in patients with human immunodeficiency virus (HIV)-negative cryptococcal meningitis (CM) has rarely been examined in the literature. We ana- lyzed the clinical characteristics and MRI findings of 65 HIV-negative patients (43 men, 22 women, age 19–86 years) collected during a study period of 15 years (January 2001–December 2015). Their underly- ing conditions included diabetes mellitus, liver cirrhosis, hematologic disorders, autoimmune disorders, malignancy, chronic obstructive pulmonary disease, adrenal insufficiency and organ transplantation, and their clinical presentations included headache, altered consciousness, fever, seizure, visual disturbance and hearing impairment. The main cranial MRI findings were basal meningeal enhancement (44.6%, 29/65), dilated Virchow-Robin space/pseudocyst (43.1%, 28/65), ‘‘dirty” cerebrospinal fluid sign (38.5%, 25/65), hydrocephalus (36.9%, 21/65), acute/subacute cerebral infarct (ASCI, 21.5%, 14/65), cryptococ- coma (9.2%, 6/65), and hazy brain base (1.5%, 1/65). The therapeutic results of the 65 patients were evaluated using the Glasgow Outcome Scale (GOS). A comparison of the good outcome group (GOS score = 4–5, n = 37) and poor outcome group (GOS score = 1–3, n = 28) revealed that both the presence of seizures and ASCI were significantly associated with the prognosis. A comparison of the groups with ASCI (n = 14) and without ASCI (n = 51) revealed that the presence of basal meningeal enhancement was a significant factor for the development of ASCI, and that this correlation may be associated with intense basal meningeal inflammation in adjacent small vessels. Ó 2018 Published by Elsevier Ltd. 1. Introduction Cryptococcus (C.) neoformans is an encapsulated yeast-like fun- gal organism which enters the human body through the respira- tory tract and has a special predilection to involve the central nervous system (CNS), resulting in cryptococcal meningitis (CM) [1]. CM usually affects individuals with defective cell-mediated immunity, especially those with human immunodeficiency virus (HIV) infection [1,2], but it can also affect individuals with an immunocompetent state [1–5]. The clinical characteristics of CM are protean, and many are known to influence the therapeutic results [1–5]. Recent studies have reported the findings of cranial magnetic resonance imaging (MRI) in both immunocompromised and immunocompetent patients with CM [6–11], however the prognostic significance of these neuroimaging findings on HIV- negative patients with CM has not been examined in the literature. Therefore, in this cranial MRI-based study, we analyzed the clinical characteristics and MRI features of 65 HIV-negative adults with CM and examined the prognostic significance of this severe CNS infection. 2. Patients and methods We retrospectively reviewed the clinical and laboratory data of adult patients with newly diagnosed CM admitted to Kaohsiung Chang Gung Memorial Hospital during a study period of 15 years (January 2001–December 2015). During the study period, 73 adult HIV-negative patients with CM were identified. Among them, 65 had an early cranial MRI study at admission and were thus enrolled into this study. The clinical and laboratory data and cranial MRI https://doi.org/10.1016/j.jocn.2018.06.044 0967-5868/Ó 2018 Published by Elsevier Ltd. ⇑ Corresponding author at: Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung, 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Taiwan. E-mail address: cwenneng@ms19.hinet.net (W.-N. Chang). 1 Equally contributed as the 1st author. Journal of Clinical Neuroscience xxx (2018) xxx–xxx Contents lists available at ScienceDirect Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn Please cite this article in press as: Tsai W-C et al. The prognostic factors of HIV-negative adult cryptococcal meningitis with a focus on cranial MRI-based neuroimaging findings. J Clin Neurosci (2018), https://doi.org/10.1016/j.jocn.2018.06.044